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j . <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to Web-App#- <br /> PROPERTY OWNER INFORMATION :: z=_ .. a ;? �, ,w;; =._ "< =-1,-:`, ";,=' CUSTOMER TO PROVIDE <br /> OWNERS c ( I r GUCA S I • ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,Stiate, ip) <br /> n Deed Restriction;CSM <br /> (0((0(07 lk(bra !K c C1-4‘ U2 53 5-6'3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR SS <br /> C9V 3- C o f(o ) at , -9 3 a 3 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION :: ; CONTRACTOR:INFORMATION. and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE • ❑ Site Plan approval from <br /> applicable township: <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.winus/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: C/ ACREAGE: P P ►ty <br /> ❑ NUMBER osologo'l"asq-gcoo-s `illt t/ir A-I Es a, q s frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> (.\ C0( 6u 1/4: 1/1/: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> (Q&&7 14e140ra <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION, ,_ r <br /> PROJECT DESCRIPTION: ? L, : <br /> ReIplaCiAl COe:k ckv , pOrC,1t r^ E G L, <br /> `-- <br /> .ia) , II 3 <br /> ❑T Is project is a new building or structure. a i4A . <br /> This project is an addition/alteration to an existing building or structure. k r- x <br /> SANITARY SERVICE: PERMIT NUMBER: � n 1 e r � <br /> ❑SEWER SEPTIC i�` `a <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) 3,- - <br /> Ti.V 2I V Z. On e � <br /> AREA TO NEAREST SQUARE FOOT: ._, .-� ,� ‘-I <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ya= <br /> BASEMENT: 1 ST FLOOR: -- ®� 40 t �.- - <br /> • r I__ a 38 4, TOTAL SQUARE FOOTAGE: ,, - ' iiir:x0,- i 3g <br /> 2ND OOR: 3RD FLOOR: l <br /> ESTIMATED CONSTRUCTION COST: s®,,� <br /> (Please round to nearest dollar) "� S��, �, F e ; / u <br /> 1613 ,, <br /> S <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes 4; ❑Don't know i'sy <br /> 2. Is there a wetland or floodplain on or near the property? ❑,Y YNNo ❑Don't know 13-c <br /> 3. Have you talked with the township about your project and are they in agreement'? (1Q <br /> Yes ❑0N 3 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes allo <br /> S 7 3 <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one) <br /> 6. Is a location survey required? (see reverse) ❑Yes ,.._,Ng ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Lld'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -4. —► <br /> 545-112(4/08) <br />